The purpose of this study was to evaluate the relationshi p between type III collagen and shoulder contracture.

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(Purpose)
We observed the BLC (biceps tendon/labrum cmplex)macroscopically using the shoulder joints of cadavers.
(Materials and Methods)
The materials were 40 shoulder joints obtained at autopsy from 22 cadavers. They consisted of 23 joints from 16 normal cadavers and 17 joints from 14 cadavers with shoulder abnormalities. The joints were divided longitudinally by a line (M) connecting the center of the BLC with that of the glenoid fossa. Ml was the distance from the margin of the cartilage to the notch in the labrum, and M2 was the width of the labrum in the same region.
(Results)
The mean value of M1 was 1.2±0.9mm in the normal group and 3.0±1.5mm in the abnormal group, while that of M2 was 3.8±0.6mm and 4.6±1.9mm, respectively.
(Conclusion)

A significant difference in MI was seen between the normal and abnormal groups (p<0.001), Which should aid in the diagnosis of BLC injury by arthroscopy.

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The long head of biceps tendon (LHB) are occasionally damaged with minor traumas in aged patients. The purpose of this study is to investigate the insertion of LHB in the aged people to find out the pathophysiology of this injury.

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There has been much controversy about the correlation between subacromial impingement and the circulation of the supraspinatus tendon (SSp). We studied oxygen tension (PO₂) at 2 and 12mm (distal and proximal points) from the insertions of the anterior, middle and posterior portions of the SSp with the 'Digital PO₂ Monitor. ' Six patients with the impingement syndrome (age: 41-53y/o, m =47.9) were examined during their operations, before and after 90°passive abduction in the scapular plane for 2 minutes, as well as their blood flow. They were compared before and after anterior acromioplasty. Two hours postmortem, nine intact cadaveric tendons (age: 21 - 45y / o, m=37.1) were similarly studied on and off the compression of lkg/cm² for 2 minutes with an F. P. meter. Their coronal histologic sections were observed subsequently. The blood flow was approximately 0 in 90° abduction and normalized soon after the arm was brought down. The PO2, which did not change in the abduction, similarly decreased (m=10.7mmHg) at all examined points in the arm-down position. Mechanical impingement might influence the PO2 in all portions of the SSp. The anterior acromioplasty prevented the PO₂ from falling. By compression, the PO₂ in cadavers decreased by 10 and 16.5mmHg at the distal and proximal points, respectively. Histologic evidences of torn fibers by compression were unclear and difficult to interpret. A PO₂ is defined as the difference of oxygen supply (circulation and interstitial-fluid diffusion) and consumption (collagen synthesis and cellular regeneration). The intracellular PO2 is lower than the extracellular one. The PO₂ decrease after an abduction or compression, and similar dynamic changes in the PO₂of surgical and cadaveric tendons made us suspect that the hypoxia might be due to the development of a fluid diffusion or the exudation of the intracellular matrix. Regeneration of the tenocytes might consume more intratendinous oxygen. Hence, the hypoxia caused by a mechanical impingement can be an accelerating factor for tendon injuries.

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We investigated the stability of the sho u lder joint. The function of the rotator cuff and scapulothoracic joint were estimated using X-rays and electromyographical examination. We related the abnormal micromovement of the shoulder motion, and the so called “skid slip” was estimated using cineradiography. with the function of the shoulder.

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Three dimensional analysis of shoulder kinematics was performed using cineradiography.

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Many authors have reported that the acromio-humeral interval (AHI) narrows in rotator cuff tears (RCT). But the percentage of accuracy of this examination is not high. We improved the accuracy and reproducibility of the diagnosis by taking X-rays under isometric abduction of the shoulders in RCT.
Two X-ra y s were examined in each of 64 patients diagnosed as cuff tear. Two A-P X-rays were taken in the standing position both under resting status and isometric abduction. The distance of AHI under isometric condition (S-AHI) was measured and compared with that of the resting position. As a control, two X-rays each of 21 normal volunteers were taken in the same manner.
In the control group the AHI was on average 11.4mm, the S-AHI was 10.3mm. In the RCT group the AHI and the S-AHI had mean values of 9.9mm and 6.9mm, respectively. In the massive RCT group, the results were 8.5mm and 3.5mm. Our diagnosis of a massive RCT, show the false negative rates of the S-AHI were significantly lower than those of the AHI.
The “S-AHI” measurement is useful as a screening-test for a massive RCT.

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The present study was undertaken to find out 1) whether this model had a repair potential,2) if yes, which cells were contributing to the repair process,3) which types of collagens appeared during the process.
A transverse incision (7mm width) was made on the supraspinatus tendon on 37 adult female rabbits. The animals were euthanized at 4 days (8 rabbits),1 week (8 rabbits),2 weeks (8rabbits),4 weeks (7 rabbits) and 8 weeks (6 rabbits). Besides HE and Masson's trichrome stainings, immunostainings of collagens (type I and III) and proliferating cell nuclear antigen (PCNA) were performed with monoclonal antibodies. At 4 days and 1 week after surgery, the stumps were covered only partly by proliferating cells coming mostly from both the bursal and articular sides. At 2 weeks, the gaps were not recognizable macroscopically. They were bridged at 4 weeks and united completely between the original fibers at 8 weeks. From the early stage of 4days after surgery, type III collagen was positively stained, while type I appeared clearly after 2weeks. PCNA were positive in the proliferating cells from the bursal and articular sides, particularly around the proliferating vessels.
The present study shows that thi s model has a repair potential, that the contributing cells for the repair are coming mainly from the bursal and articular sides with close relations with the proliferating vessels, and that two types of collagens appear at a different period after the injuries.

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The capsule of the shoulder joint plays a major role in the movement of the joint mainly in internal and external rotations. It is well known that these motions decrease with the increase of age. In this study, we measured the intra-articular pressure of the glenohumeral joint to investigate the relation of this pressure with the age of the subjects.
Fifteen normal shoulders (16-69 yrs. ) were e x amined. Under general anaesthesia, a needle was inserted into the glenohumeral joint and the position was confirmed by a roentogenofluoscopy. Saline was injected into the joint space and the pressure was recorded on a data recorder.
The intra-articular pressure significantly increased with the increased amoun t of injected saline with a correlation coefficient of over 0.91. In almost all the joints, the pressure was above 100mmHg when over 40m1 saline had been injected. The pressure was higher in older subjects compared to the younger subjects with the same amount of injected saline. The correlation of the pressure (mmHg : y) and the age (x) followed these equations; at 5m1 injected, y=0.42x -0.7, r=0.67 and at 20m1injected, y=-0.50x +46, r =0.30.
The internal and exte r nal rotation of the glenohumeral joint decreases with the increase of the subject's age and with the increase of the arm elevation. From this study, we believe that the increase of intra-articular pressure in older people might be due to less elasticity and a decrease in the volume of the glenohumeral joint capsule.

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We have reported that the natural course of rheumatoid shoulder destruction on X-ray can be classified into 5 types, i. e., the non-progressive, the hatchet, the collapse, the stiff, and the mutilating types. We can predict the type of shoulder destruction to some extent about 5-10 years after the disease onset, and this should be very helpful when selecting a treatment for rheumatoid arthritis (RA) patients with shoulder involvement. To clarify the pattern of rheumatoid shoulder destruction more meticulously, we analyzed shoulder joint destruction on computerized tomographys (CT).69shoulder joints of 35 patients with RA were the subject of this study. A radiographic grading of the RAs according to Larsen was used.12 joints were classified as grade 0,12 as grade 1,10 as grade 2,7 as grade 3,14 as grade 4,14 as grade 5. Glenohumeral transverse index (GHI), the glenoid tilting angle (GTA), the humeral anteroposterior migration (HAM) were measured, and the destruction pattern of the humeral head and was analyzed on CTs. Although the mean GHI of grades 0,1 and 2was 64%, that of grades 3 and 4 was 74%. With the destruction of the shoulder joint, the glenoid got thinner, wider and deeper. In some cases of the mutilating type, this widened glenoid was finally destroyed. The mean GTA of the superior part of a glenoid of grades 0,1 and 2 was 11 degrees tilted posteriorly, but that of grades 3 and 4 was 4 degrees tilted posteriorly. With the destruction of the glenoid, the superior part of the glenoid lost its original posterior tilt and became neutral. In few cases of grades 3,4 and 5, the HAM was greater than 5mm, but no subluxation nor dislocation were observed. The humeral head was destroyed by erosions or cysts which appeared at first at the insertion of the joint capsule. They spread and destroyed the subchondral bone.

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The purpose of this study is to evaluate the results of prosthetic arthroplasties for a rheumatoid shoulder.

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The long head of the biceps brachii (LHB) is prone to degeneration because of its complicated anatomical structure. Although there is some risk of an LHB rupture due to slight trauma, its actual incidence is low. In the present study, we wish to report on 31 tendons we have treated at our hospitals in the past 20 years. Surgical treatment was adopted for the comparatively younger patients (average age: 45.2 years,14 tendons) and conservative treatment was adopted for the middleaged and senior patients (average age: 61.6 years,14 tendons).
No patients complained of subjective symptoms, su c h as muscular weakness or instability of the shoulder. However, in order to make an objective assessment of the subjects, we selected 5 cases (key hole method for all cases) from the surgical treatment group and 4 cases from the conservative treatment group and evaluated their muscular strength by using a Cybex 6000. As a result of the objective assessment, we recognized the weakness of the biceps brachii muscle in the conservative treatment group. Impaired LHB function as a stabilizer was evaluated by the muscular strength of the intenal-external rotation at 90 degree abduction of the shoulder joint. No difference was recognized between the surgical and conservative treatment groups because the LHB did not function as a stabilizer of the humeral head, even if the ruptured LHB was surgically fixed in the bicipital groove. Conseqently, a significant decrease in the muscular strength of an erternal rotation was recognized irrespective of the treatment technique (0.02 p <0.01). This phenomenon was observed probably because the LHB function as an anterior stabilizer was lost at the time of the external rotation.
The fixation of a ruptured LHB in the bicipital groove will not recover anterior shoulder stability. This surgical tequnique, however, can be applied to primarily young patients and those patients, such as physical laborers for the recovery of the strength of the biceps brachii muscle.

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In 1982 we started to perform modified Dewar's procedure (D method) for a complete dislocation of the acromioclavicular (A-C) joint in 18 cases, but in 1988 we changed our method to percutaneous pinning (P method) and treated 27 cases thus. In this study, we compared the results of both methods.
We evaluated 13 patients (9 males and 4 females) in D method and 17 patients (16 males and 1female) in P method. The average age was 34.1 years (D method) and 30.3 years (P method). The average postoperative observation period was 8 years and 9 months (D method) and 2 years and 7months (P method).
In the modified Dewar's procedure, we added a temporary fixation of the A-C joint using two Kirschner wires. In the percutaneous pinning, we fixed the A-C joint with two Kirschner wires, one of which not passing through the A-C joint and so avoiding any osteoarthritic changes.
According to Kawabe's score, the D method scored 92.3 points, and the P method 95.8 points in average. In the X-ray findings, subluxations were observed in 6 cases (46.2% D method) and in 9cases (52.9% P method). OA changes of the acromioclavicular joint were observed in 10 cases (76.9% D method) and in 3 cases (21.4% P method). The clinical results of the Pmethod were as good as those of the D method.
Therefore, we believ e percutaneous pinning is one of the useful methods for a fresh dislocation of the acromioclavicular joint.

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The purpose of this report is to review the results of Kirschner wire fixation for fractures of the distal clavicle.
We retrospectively studied 27 cases over 3 years. According to the Neer's classification,9fractures were type I and 18 fractures were type II. The average age was 44 years in type I and 38.5 years in type II. Type I fractures were treated with a sling in 6 cases and a figure eight bandage in 3 cases. Type II fractures were divided into 2 types. One was a fracture in which the distal fragment was uncommunited, and the other was a fracture in which the distal fragment was communited. Fractures with uncommunited distal fragments were treated by transacromial fixations with Kirschner wires (13 cases) or by fracture fixations with Kirschner wires (2 cases). Fractures with communited distal fragments were treated by transacromial fixations with Kirschner wires after resections of the distal fragments and reconstruction of the coracoclavicular ligaments (2 cases) or open reduction and internal fixation with a screw and transacromial Kirschner wire fixation (1 case).
Patients with a type I fracture obtained excellent results. Of the 13 patients with a type II fracture who were followed-up for more than 3 months after their operations, one could not elevate his limb due to hemiplegia, and two had mild pain in their daily activities. Dalayed union occured in one case and nonunion occured in another. Proximal fragment displaced superiorly more than 5mm after removal of the Kischner wires in two cases, of which, one had a nonunion. All those who revealed a delayed union, a nonunion, or a superiorly displacement of the proximal fragment had an uncommunited and large distal fragment. Kirschner wire fixation may not be the treatment of choice for a type II fracture with a large distal fragment.

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Good therapeutic results can be obtained by conservative therapy for a fracture of the proximal end of the humerus in most cases. However, hemorrhagic therapy is required in patients with 3 or 4part fractures (Neer's Classification) in whom there is bone comminution. In the present study, we conducted hemorrhaic therapy on comminuted fractures and evaluated the postoperative results and optimal therapeutic regimens.
The types of fract u re were classified according to Neer's classification system was 3 part in 14patients and 4 part in 4 patients. Two of the 14 patients with a 3 part fracture had a dislocation fracture. The Surgical techniques used were percutaneous wiring in 5 patients, plate fixations in 3, a K-wire or screw fixation in 9 and a prosthesis replacement in 1. The postoperative follow-up period ranged between 6 months and 4 years and 7 months (mean: 14.8 months).
The therapeutic score was determined by the criteria established by the Japanese Orthopedic Association (J0A) was 42-100 (mean: 84.8). However, the therapeutic results were poor in 5patients aged 60 years and over, including the one in whom the prosthesis replacement had been conducted, with a mean therapeutic score of 72.2. No patient showed a faulty union or head necrosis.
Favorable therapeutic results can be obtained by open reduction in patients with a comminuted fracture of the proximalend of the humerus, but further studies are necessary on the operative tachniques and the after-treatment in elderly patients.

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We have performed hemiarthroplasty on 16 cases of proximal humeral fractures. The purpose of this study is to evaluate the postoperative results.
One of the 16 cases was male and 15 fe males, and the age at operation ranged from 64 to 85years, mean 73.2 years. According to Neer's classification, two cases were 4-part fracturedislocations, two 4-part fractures, two 3-part fracture dislocations, eight 3-part fractures, and two nonunions of the surgical neck. Follow-up periods ranged from 12 to 70 months, mean 33 months. As for the inserted prosthesis, two were Neer II, twelve biomodular, and two bipolar. Tension band wiring through the rotator cuff for fixation of both tuberosities was supplemented to the ordinal wiring. They were evaluated on pain, ROM, X-ray, and by Neer's scoring system.
No pain interrupted their daily life styles. Twelve cases obtained 90- 1 40 degrees in abduction and flexion, and 30-60 in external rotation. Another two cases obtained almost full ROM and the other two had severe restriction. In Neer's scoring system one was excellent,6 satisfactory,7unsatisfactory, and 2 failures. The causes of the unsatisfactory result seemed to be delay of operation, axillary nerve palsy, unsuitable placement of the prosthesis, and delay in the rehabilitation program. One case in which bipolar prosthesis was used was rated as excellent, and the other as satisfactory.
It seems that a secure fixation of both tuberosities and early systematic rehabilitation is essential to improve the results of hemiartheoplasty but a bipolar prosthesis may be the solution for some postoperative results.

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The purpose of the study was to follow up mid-term results of the humeral endprosthesis performed mainly for elderly patients.

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Proproception likely has a considerable role in stabilization of the shoulder by muscular action, but human shoulder proprioception has not yet been thoroughly characterized. The purpose of this study was to examine proprioception in normal shoulders and in shoulders with a history of anterior dislocation or rotator cuff tear.
Thirty normal and 20 i njured shoulders were examined, as were 10 shoulders associated with recurrent dislocation and 15 shoulders associated with rotator tear. Proprioception was tested in two ways. The first method consisted of determining in the threshold for perception of joint movement and the second method examined the ability of reproduction of joint angle, using a continuing passive movement.
There was a s t eady decline in shoulder kinesthesia with age in normal shoulders. The shoulders associated with recurrent dislocation significantly has impaired angle reproduction of joint (p <0.05), while there were no significant differences in the threshold for perception of joint movement between these shoulders and normal ones in age-matched subjects. The shoulders associated with massive cuff tear showed marked proprioceptive deficit both in perception of joint movement (p <0.002) and in the reproduction of joint angle.
The development of rotator cuff tear are about by a mechanism which is still unclear. Though deficit of proprioception may be a consequence of the process of rotator cuff tear, it may equally be primary factor in the initiation of joint damage.

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In our immunohistochemical study on the distribution of nerves in the shoulder joint capsule, we frequently found pathological nerve changes. We have investigated the clinicopathological significance of them.
Thirty-five shoulder joint capsules obtained from 20 autopsy cases (mean 61.9 years,12 males and 8 females) were cut into 32 slices. Ten μm sections of each slice were stained immunohistochemically using anti-S-100 protein antibody and studied histomorphometrically. The axillary nerve portion from the 10 shoulder joints of 5 other cadavera were studied on the distribution of similar changes along the course of th nerve.
Characteristic degeneration of nerves in the shoulder joins is recognized in 26 of 35 capsules (74.3%). Histological features of the nerves were 1) perineurial thickening,2) myxoid chan ge and 2) hyaline globular structures regarded as Renaut bodies in the endoneurium. These degenerative features resembled those found in the fusiform swelling in the branch to the teres minor muscle. thought to be caused by chronic nerve compression. Sixty percent of the degenerated nerves occurred in the antero-and postero-inferior portions of the capsule. In all ten cass, the pathological nerve changes in the axillary nerve occurred at its bifurcation into the teres minor. These alterations were not seen in a 16 weeks male and 19 y. o. female, but found in a 22y. o. male studied for comparison. Quantitative evaluation revealed that the number of nerves with myxoid degeneration was significantly increased in slices in which the number of degenerated nerver is less than 20% and nerves with perineurial thickening was significantly increased in slices in which the ratio of the number of degenerated nerves is more than 20%. Renaut body formation in the latter slices tended to be more numerous and larger than in the former cases. No correlation between the age and the severity of these numerous and larger than in the former cases. No correlation between the age and the severity of these degenerative nerve changes was noted. Histomorphometrical study revealed the DMIN and DCIRCLE of degenerated nerves were significantly increased.
Although apparent macroscopic changes around the shoulder joint have not been found, we suggest that repetitive shoulder movement and compression of the axillary nerve and inferior joint capsule might result in this form of nerve degeneration. Asymptomatic nerve degeneration occurs frequently in the shoulder joint capsule.

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There have been few studies on the distribution of nerves in the cor a co-humeral (C-H) ligament. In the present study, we have immunohistochemically demonstrated the distribution of nerve fibers in the C-H ligament and its surrounding tissues using a monoclonal anti-neurofilament protein (NF)antibody. Specimens were obtained from 20 cases,40 joints at pathological dissections. The cases consisted of 7 males and 13 females; the age range was from 29 to 98 years (mean 78 years). The CH ligament and its surrounding tissues including the rotator interval were excised en bloc and fixed in Zamboni solution. Paraffin and vibratome sections and whole mount preparations were prepared, and subjected to immunohistochemical staining using the NF antibody. In this study, NF-positive nerve fibers were observed in the C-H l i g ament and its surrounding connective tissues in parafin and vibratome sections. In the whole mount preparations, likewise, networks of NF-positive nerves were visualized. From the results obtained, the distribution of nerve fibers in the C-H ligament and its surrounding tissues was clarified. Further, three dimensional distribution of nerve fibers was successfully observed by immunohistochemical staining with the NF antibody in the whole mount preparation. The C-H ligament and its surrounding tissues are relatively abundant in nerve fibers, partially composing a neural network.

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The purpose of this study was to investigate how an anomalous musculotendinous structure affects the surgical procedure.
Subjects were 11 anomalous musculotendinous structures confirmed at surgery in 11 shoulders. We analysed these structures from our anatomical and surgical findings.
In 8 patients, the anomalous muscles originated in the subsca p ularis tendon were thought to be the accessory head of the biceps brachii. In 2 patients, the anomalous muscles originated in the conjoint tendon were thought to be the coracobrachialis brevis muscles. In 1 patient, the anomalous muscle originated in the subscapularis muscle was thought to be the subscapularis minor muscle. None of them severely hindered the surgical process. However they masked the anterior brachial circumflex arteries and veins in 3 patients. Large anomalous structures obstructed the view of the surgical field inferior to the shoulder.
In conclusion, the most f r equent form of anomalous musculotendinous structures in the anterior shoulder was the accessory head of the biceps brachii. A surgeon may become confused if he is not aware of this.

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Purpose
We wish to point a connection between the clavicle and the scapula in skeletal structures of the upper extremities. However, except for the motion of elevation, the movements of the scapula and clavicle had been rather neglected so far. We have previously reported that the scapula movement was 50° from the trunk horizontally, using a VICON motion analysing system in male in their 30s and concluded that the gleno-humeral rhythm existed, not only in the up-and-down motions but in other motions, as well. Here, we will report on how the glenohumeral rhythm changes with ageing, using an ordinary graduator.
Methods
3 and 5-year-old infants (46-27 males and 19 females), and adults in their 30s (20 males) and 60s (23 males) were the subjects. We investigated the angles between the bilateral spines at the positions of a) 90° abduction, b) 90° flexion, c) maximum adduction and the adults were measured at positions of d) maximum abduction of the arm.
Results
We obtained the following results: the angle between a) and b); infants - 79° (ave. ),30s - 58°(ave. ),60s-51° (ave. ), between b) and c); infants - 16° (ave. ),30s-13° (ave. ),60s - 7° (ave. ), and between a) and d); 30s-15° (ave. ),60s-7° (ave. ). There was no sex difference in the infants.
Discussion
The results we obtained, clarified that the scapula motion range decreases considerably with ageing. It is an important phenomenon and one of the factors of diseases in the middle-aged and elderly.

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We treated a case of incomplete rotator cuff tear, in whom osseous deformities were obserbed in the acromion and the greater tubercle. Here is the case report.
A 47-year-old woman complained of pain in her left sh o ulder for about 10 years without trauma. Our intial examination on March 24,1992, tenderness had developed on the greater tubercle.
The range of motion was limited at abduction. Her X ray film demonstrated hyperostotic change of the acromion and the greater tubercle, and free boodies within the subacromial bursa.
The MRltest showed the rotator cuff with an irregular shape.
No leakage of contrast medium was seen at arthrography of the shoulder joint. The locational relation of deformity between the acromion and the greater tubercle was defined by 3D-CT.
We treated the patient in a conservative manner, but failed.
Thus we operated on April 20,1994. The hyperostot i c region in the acromion was resected with osteoplasty. The bursal surface of the rotator cuff showed an incomplete tear.
The tearing region was resected and repaired. Her symptoms improved aft e r the operation. It has been reported that the rotator cuff can be torn by an osteophyte of the acromion.
It this case, it was assumed, from the consideration of sudden aggrava t i on of shoulder pain in the last stage of the long-term clinical course, that osteophytosis occurred in the acromion and the greater tubercle as a result of repeated subacromial impingement, eventually leading to an incomplete tear of the rotator cuff. This case provided valuable information needed to clarify the pathogenesis of an incomplete rotator cuff tear.

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Acromioclavicular (AC) injuries in children are very rare, and confused with fractures of the distal end of the clavice. When the clavicle is displaced superiorly out of the periosteal tube and the coracoclavicular ligaments remain intact to the periosteal tube, it is called a pseududislocation. There has never before, to our knowledge, been a report on pseudodislocation of bilateral AC joints. We wish to report one rare case of bilateral AC pseudodislocation, treated conservatively which ragained normal function of the choulders.
The case is a 15-year-old bo y. He was injured in a traffic accident in July,1992. He had bilateral AC pseudodislocation as well as a severe head injury. The types of pseudodislocation were type V in the left side and type III in the right side, according to Rockwood's classification. The injuries were treated conservatively due to his mental deragenent. Four weeks after the injury there was an extensive formation of like a 'second' clavicle in continuity with the acromion. The distal end of the clavicles became a typical Y-shaped. MRI showed that the deltoid seemed attached to the newly formed bone. At the time of writing, he had been followed for 1 year and 10 months after injury, and had a full range of motion. There was no problem in ADL and he had no significant shoulder pain. The JOA scores were 76 in the left side and 81 in the right side, because a slight tenderness on the feft AC joint and dislocation of bilateral AC joints. In appearance, the projection of the clavicles became inconspocuous. As he injured bilateral joints, there is ebident ploblem.
It is controversial whether operative procedures for this injury are needed or not. Our findings suggest that conservative treatment might be, at least, a choice of therapy for this injury
.

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Pupose The authors previously reported that there were little predisposing osseous factors in traumatic anterior instability such as the anterior glenoid tilt and humeral retrotorsion. The purpose of this study is to evaluate the usefulness of our method for measurement of the gleno-tilting angle (GTA)and humeral retrotorsion angle (HRA) and review the predisposing osseous factors.
Materials and Methods Using a Logitec K-510 digitizer, the GTA and HRA were calculated from seven points which were measured at anterior, posterior and medial edges of the scapula, two maximum diameter points of the humeral head, the medial and lateral epicondyles in CT scans. The glenoid and humerus models that had various estabished GTA and HRA were examined again by our method to possibly correct the measurements. Each model was examined three times by 10 orthopaedic surgeons and the results were evaluated with a simple liner regression. Eighty-two shoulder (age 15-32, average 21,72 males,10 females) in traumatic anterior instability were examined and compared with 48 controls (age 15 - 39 average 23,36 males 12 females). The Kruskal-Wallis test was performed on the involved side, the uninvolved side and control shoulders.
Results The regression lines of GTA and HRA were Y =1.01X 0.36 and Y =1.07X 4.99. and HRA in the involved sides were 0.8° ±4.5°,29.0° ±12.5°, in the uninvolved were 0° ±4.1The GTA,29.8° ±12.8° and in the controls were 1.9° ±4.5,32.3° ±11.9° (mean±1SD). The GTA and HRA were not significantly different between each group. Conclusion There are minimal errors in the measuring the GTA and HRA using our method. The consider that there are little predisposing osseous factors in traumatic anterior instability.

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Cineradioarthrography was used to determine the etiological factors of anterior instability of the unstable shoulder in the horizontal plane.
Fifty-seven patients with a traum a tic unstable shoulder and forty-two patients with an atraumatic unstable shoulder were evaluated. One hundred shoulders without anterior instability were selected as the control group. Axial cineradioarthrography was performed while extending the arm from the neutral position until it reached its maximum extension in the horizontal plane.
Regarding the mean size of the glenoid, traumatic and atraumatic unstable should e r s were significantly smaller than those in the control group (P<0.01). As for the mean size of the anterior labrum, traumatic unstable shoulders were significantly smaller than those in the other two groups (P<0.01). In case of traumatic unstable shoulder, the larger the size of glenoid with or without anterior labrum was, the larger the distance of the anterior shift was. As for atraumatic unstable shoulder, the smaller the size of the glenoid with or without anterior labrum was, the larger the distance of the anterior shift was.
The etiology of anterior i n stability in patients with a traumatic unstable shoulder was thought to be not a Bankart lesion but abnormal laxity of the capsule. As for the atraumatic unstable shoulder, one of the etiological factors was thought to be hypoplasia of the glenoid.

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There are arthrography, CT arthrography, MR arthrography among the assessment techniques of the anterior capsular mechanism of the shoulder joint, but a puncture into the shoulder joint is essential. An injection into a joint is an invasive procedure, although it is slight.
We assessed the MR imaging of recurrent shoulder dislocations using a non-invasive technique to the shoulder joint.

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Recently MR imaging has been proposed as a possib l e replacement for more conservative imaging. We investigated the use of MR imaging in the diagnosis of shoulder instability. One hundred and twenty-four patients who had symptoms and signs suggesting shoulder instability underwent MR imaging with and without intraarticular Gd-DTPA. Spin echo Ti-weighted images were obtained in the axial plane in a 1.5-T MR system. Surgical findings of glenoid labra were available in 55 patients. Labral tears were diagnosed in 42 out of the 55 by MR imaging. Labral tears were surgically confirmed in 40 of the 42, but not in the other two. The labrum was diagnosed as being normal in 13 of the 55 by MR imaging. The detachment of labra were surgically found in one of the 12, but not found in the other 11. We think MR arthrography could clearly visualize labral tears.

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For detection of abnormalities of the anterior inferior glenohumeral ligament (AIGHL), preoperative MRA and CTA were performed in 35 patients with an arthroscopic diagnosis of traumatic anterior instability in 27 cases, of subacromial bursitis in 5 cases and of other shoulder pathology in 3 cases. MRA was performed with Shimazu a 1.0T SMT100 and after the intraarticular injection of Gd-DTPA, transverse and oblique sagittal images were obtained. CTA was performed with a Shimazu 4500TE, and transverse and reformatted oblique sagittal images were obtained. Using these images, the AIGHL was evaluated for attachement to the glenoid rim, medial displacement, redundancy, and thickness in comparison with the arthroscopic findings.
The imaging findings were consistent with the arthroscopic findings for 77% of M RA transverse images (tr),75% of MRA oblique sagittal images (sag),78% of CTA tr and 75% of CTA sag regarding the site of attachment to the glenoid rim, and for 78% of MRA tr,78% of MRA sag,81%of CTA tr, and 75% of CTA sag regarding medial displacement. Consistient findings were also obtained for 66% of MRA tr and 48% of CTA tr regarding redundancy, and for 65% of MRA tr regarding thickness. However, CTA could not evaluate thickness. For evaluation of the attachment site and medial displacement of the AIGHL, both MRA and CTA were useful. MRA was superior to CTA for evaluation on redundancy and thickness.

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The purpose of this study is to clarify the capability of conventional MRI without any intraarticular contrast agents for the classification of a Bankart lesion.
Twenty six shoulders with traumatic anterior instability were scanned in axial plane under the field gradient echo method. Assessment of a Bankart lesion was done on several slices between mid protion and the inferior edge of the glenoid on each shoulder. Labral shapes were classified into grade 1 with an apparent labral figure around the anterior glenoid edge or grade 2 without one. Arthroscopic findings were classified into two groups according to the condition of the anterior part of the inferior glenohumeral ligament (AIGHL). Fifteen shoulders had well developed thick AIGHLs and were classified into group N (including type 1,2n or 3n by Kurokawa's method). Eleven shoulders with poorly developed or frayed AIGHL were categorized group A (including type 2a,3a or 4a).
The pe rcentage of grade 2 MR finding was statistically different between that in group N (6.7%)and that in group A (69.7%). Shoulders that had no grade 2 finding on any slices were 13 of the 15in group N and 1 of the 11 in group A. The difference of the ratio was statistically significant too.
A grade 2 MR finding seen even in one slice indicates that the shoulder belongs to group A, for which an arthroscopic surgery is poorly indicated.

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Caspari procedure is performed on anterior shoulder instability using a suture punch to place multiple sutures into the detached anterior labrum. If no anterior labrum is present or if the labrum is thin and atrophic, this procedure is difficult. Then in this study, the size of the anterior labrum and the type of labral disorders (such as tear, detachment and defect) were evaluated by MR arthrography and arthroscopy.

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The purpose of this study is to know the pathology of self-reduction in dislocated shoulder from the results of its manipulation under general anestesia and the arthroscopic findings.

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Sixty eight patients with traumatic anterior shoulder instability who were treated with arthroscopic Bankart repair (Caspari's technique) were reviewed retrospectively and the factors related to the poor results were analyzed. The mean age at operation was 21 years old (13-56) and the mean follow-up period was 28 months (12-58). Bankart lesions were arthroscopically classified into five types as proposed by Yoneda. Type 1 Bankart lesion was recognized in 18 patients, type 2in 28, type 3 in 16, and type 5 in 6.22 of them played collision sports before operation. The clinical results were assessed by Rowe's criteria. A multivariate analysis of the causes of the poor result was made.
Regarding the clinical results,48 of the 68 were excellent,10 were good, and 10 were poor. All the patients with poor result had postoperative re-dislocations with a recurrent rate of 15%. The mean limitation of external rotation at 90 degrees abduction was 5.9 degrees (0-30), and a transient suprascapular nerve paralysis was recognized in 2 patients. The patients with significantly poor results were those; patients who could not keep the postoperative fixations, had type 2 or 3 Bankart lesions, played collision sports pre-operatively, had thin ant. sup. glenohumeral ligaments, or were repaired with less than four sutures.

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Large substantial tears of the anterior capsule are infrequently described lesions associated with recurrent anterior shoulder instability (RASI). We reviewed three patients in a series of 295patients with RASI who underwent Bankart procedures or its modification, where significant capsular tears were found.
The three patients were all men aged from 20 to 24 years at the time of the initial traumatic dislocation. The intervals between the time of the initial dislocation and that of surgery ranged from 8 to 24 months, and the total numbers of dislocations in that interval ranged between four and five. The anterior apprehension test was positive in all cases, but the absolute amount of anterior instability varied.
Pneumoa rthro-CTs demonstrated an antero-inferior protrusion of the articular cavity in all cases resembling a diverticulum. Large capsular tears with intact subscapularis muscles found at surgery included two longitudinal tears from the middle glenohumeral ligament (GHL) down to the inferior GHL located in the middle portion of the capsule and a longitudinal tear of the anterior half of the inferior GHL in the capsuro-labrum junction. Their margins were hypertrophied and rounded by a scar. The diverticula formed by a thin membrane were found between these tears and the subscapularis muscles, and connected with the articular cavity. Combined lesions in addition to the capsular tears included a slightly, a moderately detached labrum and a glenoid shearing fracture with an intact labrum. There were no large Hill-Sachs lesions. Stability of these shoulders was restored by a Bankart repair followed by a suture repair of the capsular tear, and no patient has experienced a recurrent dislocation.
Although substantial tears of the anterior capsule are rare lesions in cases of RASI, these lesions can be diagnosed by arthro-CT. In these cases, a wider exposure of the capsule is needed for surgical reconstruction.

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We wish to report the results and complications of 90 cases investigated and which were followedup over one year after surgery. Our modification of Boytchev's procedure, in which the subscapular muscle is cut and resutured on the conjoined tendon after capsulorrhaphy, was performed in 62cases. The mean age was 24.4 years old. The mean follow-up period was 62.5 months. Transient musculocutaneous nerve palsy was recognized in three cases, which recovered within seven months. One case needed a reoperation because a painful crepitation appeared 27 months after surgery. Recurrence was recognized in four cases. The recurrence rate was 6.4%.
In the modified Bristow's procedure, the glenoid is exposed and the coracoid process is transferred on the anterior-inferior glenoid rim then shifted the anterior capsule and subscapular muscle, which we added. The results were evaluated in 28 cases. The mean age was 23.2 years old. The mean follow-up period was 38.2 months. Recurrence was not recognized. Slight deformity of the humeral head was recognized in two cases. Screw breakage occurred in two cases.
These complications could be avoided if we take care not to rotate the shoulder externally too excessively.

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In peripheral nerve palsy, we often find the change in signal intensity of palsied skeletal muscles on MR imaging. The purpose of this study is to clarify the relation between the MRI findings and clinical examinations of the suprascapular nerve palsy.
Subjects were 9 patiants with suprascapular nerve palsy who had been undergone the MRI examination. In 6 of 9 cases, we could find ganglion cysts located on the spinoglenoid notch, and extirpated them by the operations.
On Ti-weighted images, signal intensity of infraspinatus muscle (ISP) was high in 3 cases, but that of supraspinatus muscle (SSP) was all normal. On T2-weighted images, ISP was high in 5cases and SSP was high in one case. In complete palsied muscles, diagnosed by EMG as E. S. (electrical silent), MRI showed all of them high signal intensity on T2 weighted images. In 2 cases, we confirmed that the high signal intensity of palsied muscles changed into normal after they had recovered from the palsy.
High signal inten s ity of palsied muscles on MRI is related to the grading of their severity. MRI is useful examination on peripheral nerve palsy for not only detection of ganglion cysts, but also the staging of paralysis.

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The purpose of this study was to evaluate the three-dimensional movement of the scapula in suprascapular nerve palsy and axillary nerve palsy.
Two patients with suprascapular nerve palsy, two with axillary nerve palsy and four with both nerve palsies were examined. As a control group, eight normal subjects were exermined.
The active arm elevation was allowed in both the sagittal and scapular p lanes. Eight points were determined as marking points of the spine, the sternum, the clavicle, the scapula and the humerus which were identified every thirty degrees. These were recorded on three VCRs. A threedimensional analysis system (ARIEL^TM) was employed.
In suprascapular nerve palsy, the upward rotationof the glenoid cavity occured in the early phase of arm elevation, which occures in the late phase in axillary nerve palsy. And the subscapular fossa tilted less mediallythan that of the control group, in suprascapular nerve palsy.In patients with both nerve palsies, the glenoid cavity rotated upward and the subscapular fossa tilted upward, markedly. In isolated infraspinatus palsy, the scapular movement was similar to that of the control group. When the paralytic muscle was restored, the scapular movement changed to a similar pattern as that of the unaffected side. This method is useful for the quantitative functional evaluation of shoulder girdle nerve palsy.

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From 1980 to 1994, fourteen patients with a paralyzed shoulder underwent reconstruction surgery by muscle transfer in our hospital. The causes of paralysis were brachial plexus injury (root avlusion) in nine, four birth palsies and one with axillary nerve palsy. The trapezius and the levator scapulae muscle transfer was carried out in seven cases of brachial plexus injury and in one case of birth palsy. The trapezius, the levator scapulae along with the rhomboideus muscle transfer was carried out in two cases with brachial plexus injury. In two case of birth palsy, instead of the rhomboideus muscle, the latissimus dorsi muscle was transferred. Only the trapezius muscle transfer was performed in two cases, one each in birth palsy and axillary nerve palsy. In brachial plexus injury cases, the abduction angle of the shoulder improved to 46° (ranged from 20° to 80°)after the operation. The trapezius and levator scapulae muscle transfer are effective in the shoulder recontruction for patients with a brachial plexus injury from the functional point of view. In patients with birth palsy, it was 78°, ranging from 40° to 100°. The patient with axillary nerve palsy showed excellent result with 160° arm elevation.
For shoulder reconstruction with a root avlusion, we believe that the results achieved with the trapezius and the levator scapulae muscle transfer were satisfactory. Therefore, these muscle transfer methods should be in a surgeon's mind before dicididing on arthrodesis.

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We reviewed the results of those cases on which reconstruction surgery on the paralysed shoulder had been performed and evaluated the significance of the transfer of the latissimus dorsi muscle especially in early stage cases of the injury.

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The purpose of this study is to evaluate of the long-term results of mul t iple muscle transfer to restore shoulder function in birth palsy. From 1979, in eleven patients with shoulder dysfunction due to birth palsy, we performed Harmon's deltoid shift, in particular, combined Ober's biceps transfer, Saha's trapezium transfer and Hoffer's latissimus dorsi transfer. The postoperative evaluation were consisted of active range of motion, daily activities and subjective satisfaction of the patient. The follow up period averaged of 11 years. The average gain of active flexion of the shoulder was 37°. Those was -20° in extension and 33° in external rotation. Only 5 cases were able to wash the hair. Only 5 cases satisfied with their results. Multiple muscle transfer is an useful method to reconstruct the function of active elevation and external rotation in birth palsy. However a half of patients in birth palsy unsatisfied with the results due to muscle weakness for ADL.

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To reconstruct a shoulder paralyzed by brachial plexus injuries, we performed multiple muscle transfers of the trapezius, latissimus dorsi and teres major. In this paper we will report on the surgical results and its postoperative management.

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We assessed the functional results of a muscle transfer for a paralyzed shoulder due to brachial plexus palsy. From 1983 to 1993,30 muscle transfers were performed. The patients were diagnosed as follows; seven of total type, fourteen of upper type and nine of terminal branch type such as combined injiries of the axillary and suprascapular nerve. All the patients except one were male and their ages at the operation ranged from 16 to 65 years old. Time from the injuries to muscle transfer were ranged from one month to 52 months, average 14.8 months. To restore the prime mover, an original latissimus dorsi transfer to t h e anterior deltoid (Itoh et al, J Bone Joint Surg.69 - B: 647 - 651,1987. ) was performed on twelve patients and an upper trapezius transfer was performed on three patients. To restore the steering group, a latissimus dorsi transfer to the infraspinatus was carried out in six cases. Five of them had their operations within five months of injiry. They had severe suprascapular nerve damage and muscle transfer were carried out as the primary reconstruction.
To restore the prime mover and the steering group, combined muscle transfers were performed on nine patients. Four of them were combined with a latissimus dorsi transfer to the anterior deltoid and a teres major transfer to the infraspinatus were performed.
The average follow up period was 64 months. Postoperative results were evaluated by an original point system including active range of motion in elevation and external rotation, muscle power and stability of the shoulder joint. In the over-all results, eleven patients were excellent, ten good, five fair and four poor. All the patients were obtained excellent results in the terminal branch injury group. Tweleve of the 21 patients in the upper and total type group were evaluated as good or excellent. Only four patients had a problem of shoulder instablity. We recommend. a muscle transfer as the reconstruction of a paralyzed shoulder rather than arthrodesis.

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